Strokes, Cognition, Depression, and Return to Work

I’ve recently been thinking about cerebrovascular accidents, particularly first onset stroke, and I wanted to share a few things from my literature review.

One thing that surprised me in my disability work is the number of cases I review for younger people having strokes. I was familiar with cerebrovascular accidents (CVAs) in special populations at younger ages, for instance, sickle cell disease (the rap legend, Prodigy, who died earlier this summer, at my age, has been vocal about his experience of sickle cell disease), but I was surprised by the number of examples that did not seem to be special cases like SCD.

The cause of Prodigy’s death has not been released, although there are increased rates of stroke in people living with sickle cell disease. Meanwhile, stroke in the general younger population is also getting more common (image: Wikimedia)

It turns out, this is not just a coincidence. Kissela et al. (2012) looked at a large, Midwestern (Cincinnati and Northern Kentucky, actually, someplace we went for vacation earlier this summer) sample, representing Americans of European and African ancestry, at multiple times between 1993 and 2005. The mean age at stroke was still pretty high, but dropped over this time, from 71.2 to 69.5. Meanwhile, the proportion of strokes happening under age 55 increased significantly, from 12.9% to 18.6%. In addition to finding higher rates of CVA among African Americans, it found increasing rates in younger populations, including in the 20-44 population I had noticed in my work with the disability system. In the sample, the raw incidence of CVA in that youngest population during this period of a dozen years went up 26% for African Americans, and doubled for European Americans. Like older Americans, these younger Americans mostly had ischemic CVAs, but actually a slightly higher percentage of hemorrhagic CVAs relative to older adults. The results are not overall driven by increasing rates of CVA – in fact, CVAs are becoming somewhat less common, overall, in the US (at least in men). The authors felt their data did not shine a clear light on why this is happening, although they did note a much larger contribution of coronary heart disease in their young population than in older adults. So in any event, I’m not imagining things, strokes are a consideration for a younger population than they used to be.

I’ve found in the medical practices I see, often, the physical disabilities of a first, mild stroke are emphasized. This means patients often have little or no information about neuropsychiatric impacts, often not even evidence that a decent mental status examination was done, whether informally, or via something like the Montreal Cognitive Assessment (MoCA), and likewise, psychological adjustment is rarely discussed. This is somewhat surprising, because the evidence suggests usually complete recovery from a first, mild stroke in physical functioning, at least to the point of ADL recovery, fairly quickly, whereas the lingering issues are often neuropsychiatric, although it is less clear how much these affect return to work (RTW).

Research seems to suggest that many people do return to work post-stroke with some level of mild cognitive impairment, but the extent of this, particularly losses in executive functions, might play a role in who succeeds and who does not. (image: Fotolia)

Fride et al. (2015) looked at first CVA in a sample in Tel Aviv, Israel, looking at first CVA, in individuals who were working before their stroke. The good news is that 70% of their sample RTW’d in three months. Using very simple screening measures of depression, mental status, and executive functions, they found that age and gender were not predictors of RTW, but a testing measure of executive functions was as strong a predictor as return to ADLs. Interestingly, the mean MoCA scores were 22.6 for those who had not RTW’d and 24.6 for those who had, and this was a statistically significant difference, but note that these means are both impaired, suggesting that many of those who were working were able to do so in spite of some level of mild cognitive impairment that was visible even on very rough measures. Bonner et al. (2015) looked at a similar question in Trivandrum, in the Southern Indian state of Kerala. Their results were slightly different. They looked at a younger population, and they found better RTW in those <50 years old, although their total sample RTW rate was actually lower (50% vs. 70%, in spite of a longer window, 3-24 months status post CVA). They likewise found evidence that those who were successful in RTW did have some neurocognitive limitations, commonly including some residual aphasia, and also commonly depression and anxiety, and in their sample, younger workers in professional settings were more likely to RTW, possibly because of greater ability to meet their needs with workplace accommodations. A Nigerian study, Peters et al. (2013) found a lower rate (50%) of RTW, but interestingly, in Europe, van der Kemp et al. (2017) also found only a 50% RTW at the same rate as prior to the injury (72% working, but 22% working less than previously). Like Fride, they found a small but significant MoCA difference, 25.6 for RTW vs. 24.3 for non-RTW, again, this suggested half of the RTW subset of the sample had what we could consider mild impairment on this screen.

So, overall, the evidence is a little murky. There are significant issues with success in return to work in people who have a first stroke, and much of the data suggests that, although many do return with some mild level of cognitive deficits, as well as potentially with some level of anxiety / depression, the extent of these factors may play a big role, even if they are not gross deficits.

Time spent understanding and analyzing the task demands of a patient’s line of work is time well spent (image: Fotolia)

Bringing this back to my professional experience, in general, we should be making sure that the neuropsychiatric needs of patients are being met, that they are being screened for cognitive dysfunction at a level beyond asking if they are “alert and oriented,” that we are asking about their adjustment, and that we are providing treatment where appropriate, both for cognitive remediation, and management of anxiety / depression or other health-related psychological factors (see Hutton and Ownsworth, 2017, for some great ideas on how to conceptualize this in younger stroke survivors). Forensic neuropsychologists should not just focus on memory, but should look carefully at areas like executive functioning, which involves many different parts of the brain working in coordination (not just the frontal lobe), and of course, they should pay close attention to psychological adjustment. We should, at the same time, not be perfectionists – the evidence does not suggest these skills need to be 100% back to premorbid levels to succeed at RTW. We should take the time to understand, however, what skills are particularly crucial in the RTW position, such as ability to solve various kinds of problems, the level of flexibility needed and unpredictability dealt with, the social vs. technological demands of the work, and so on.